Original Article
Determinants of Immunization Coverage in Lucknow District Pratibha Gupta, Daya Prakash, Jyoti Prakash Srivastava Department of Community Medicine, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India
Abstract Background: Immunization remains one of the most important public health interventions and a cost-effective strategy to reduce both the morbidity and mortality associated with infectious diseases. Over two million deaths are delayed through immunization each year worldwide. Aims: This study sought to identify specific factors associated with immunization coverage in order to advance improved intervention, policies/strategies therefore raising overall immunization coverage. Materials and Methods: A cross-sectional study was conducted among a total of 198 children aged 12-23 months at Urban Health and Training Centre (UHTC), Era’s Lucknow Medical College, Lucknow, over a period of 6 months i.e., from July 2012-December 2012. Data were collected, compiled and tabulated using Microsoft Excel and analyzed using SPSS 17.0 version. Results: A total of 198 children of age 12-23 months were included in this study, of which 74.7% of children were fully immunized, 11.1% were partially immunized and 14.1% were not immunized at all. The most common reason for partial or nonimmunization was family problems (24%) of the respondents followed by lack of knowledge of immunization (20%), and fear of side effects (16%). The odds of risk of partial/non-immunization in illiterate women is 5.78 more than the graduate women (P = 0.039). Conclusions: Although in the present study, majority of the children were immunized, it is still not up to the mark. We have to make it 100%, so that we can reduce mortality due to vaccine-preventable diseases. Increasing awareness and reducing fear of side effects of immunization among parents through health education, counseling, etc. can increase the percentage of immunized children.
Keywords: Children, Determinants, Immunization, Mothers, Urban areas Address for correspondence: Dr. Pratibha Gupta, 5/351, Viram Khand - 5, Gomtinagar, Lucknow-226 010, Uttar Pradesh, India. E-mail: [email protected]
Introduction Immunization remains one of the most important public health interventions and a cost-effective strategy to reduce both the morbidity and mortality associated with infectious diseases. Over two million deaths are delayed through immunization each year worldwide.[1] Despite this, vaccine-preventable diseases remain the most common cause of childhood mortality with an estimated three million deaths each year.[2] Uptake of vaccination services is dependent not only on provision of these services, but also on other factors including knowledge and attitude of mothers.[3,4] Access this article online Quick Response Code:
Website: www.najms.org
DOI: 10.4103/1947-2714.152076
36
According to the Global Routine Vaccination Coverage (GAVI) 2010, about 19.3 million children were not fully vaccinated and remained at risk for diphtheria, tetanus and pertussis, and other vaccine-preventable causes of morbidity and mortality, and about 50% of these children are from India, Nigeria, and Congo.[5] The most important indicators mentioned in the Millennium Development Goals (MDGs) are the under-5 mortality rate (U5MR), infant mortality rate (IMR) and proportion of 1-year-old children immunized against measles (P1MV). About onequarter, or 25%, of under-5 mortality is due to vaccinepreventable diseases.[6] The World Health Organization (WHO) launched the Expanded Program on Immunization (EPI) in 1974 globally with the focus on prevention of the six childhood vaccine-preventable diseases by the year 2000. This was endorsed by the Government of India in 1978.[7] Later, on November 19, 1985, the Universal Immunization Program (UIP) was introduced in India with the objective to cover at least 85% of all infants by 1990.[8]
North American Journal of Medical Sciences | Feb 2015 | Volume 7 | Issue 2 |
Gupta, et al.: Determinants of immunization in Lucknow
Further, a national socio-demographic goal was set up in National Population Policy (NPP) 2000 to achieve universal immunization of children against all vaccinepreventable diseases by 2010.[9] In addition, evaluation of immunization coverage provides evidence whether substantial progress toward achieving vaccination targets is being made. Such positive evidence is required for continuing support from donor supported initiatives like the Global Alliance for Vaccines and Immunizations (GAVI).[10] The current study seeks to determine whether the situation has improved since and to more fully identify risk groups and reasons for under-immunization. This study sought to identify specific factors associated with immunization coverage in order to advance improved intervention, policies/strategies and therefore raising overall immunization coverage.
Materials and Methods The present study is a cross-sectional study conducted among children aged 12-23 months at Urban Health and Training Centre (UHTC), Era’s Lucknow Medical College, Lucknow, for a period of six months i.e., from July 2012 to December 2012.
for calculation of percentages, and Chi-square test was applied to find out various statistical associations.
Results A total of 198 children of 12-23 months of age were included in this study of which 100 were males and 98 were females. Total 80.8% of children were Muslims and 19.2% were Hindus. In all, 76.8% of children belonged to nuclear families and 23.2% belonged to joint families. Parents of most of the children were educated. Only 37.4% of fathers and 22.2% of mothers were illiterate [Table 1]. Among immunized children, majority (83.8%) of the children were delivered at government/private hospital and only 16.2% of the children were delivered at home [Table 2]. Immunization status was ascertained by mother’s recall accompanying the child. In present study 74.7% of children were fully immunized, 11.1% partially immunized and 14.1% were not immunized at all. The
Table 1: Socio-demographic characteristics of children between 12-23 months Variables
Sampling technique The present study was conducted during July 2012 -December 2012. A total of 198 children aged 12-23 months attending outpatient department (OPD) at Urban Health and Training Centre (UHTC), Era’s Lucknow Medical College, Lucknow were included in the study. This study was conducted after the ethical clearance from the ethical committee of Era’s Lucknow Medical College, Lucknow.
Tools of data collection The investigating tool used is a preformed, pretested questionnaire. Questions regarding biosocial characteristics and immunization status of the children were asked from the mother accompanying the child. In case the mother was not present, then any other person accompanying the child was interviewed regarding biosocial characteristics and immunization status. As this study was conducted among mothers attending OPD at urban health center, so the immunization status was determined on the basis of mother’s recall and record at the urban health center. Definitions of key indicators were taken from NFHS-3, India.
No. (198)
% (100)
38 160
19.2 80.8
152 46
76.8 23.2
100 98
50.5 49.5
74 38 74 12
37.4 19.2 37.4 6.1
44 60 84 10
22.2 30.3 42.4 5.1
140 58
70.7 29.3
Religion Hindu Muslim Type of family Nuclear Joint Gender Male Female Father’s education Illiterate Primary/Junior Secondary Graduate and above Mother’s education Illiterate Primary/Junior Secondary Graduate and above No. of living children within the family 1-3 4 and above
Table 2: Place of birth
Statistical analysis
Place
Data were collected, compiled and tabulated using Microsoft Excel and analyzed using SPSS 17.0 version
Govt./Private hospital Home
North American Journal of Medical Sciences | Feb 2015 | Volume 7 | Issue 2 |
No. (198)
(%)
166 32
83.8 16.2
37
Gupta, et al.: Determinants of immunization in Lucknow
percentage of non-immunized children were more among female children (20%) [Table 3]. Most common reason for partial or non-immunization was family problems (24%) of the respondents followed by unawareness of immunization (20%), and fear of side effects (16%). Other reasons were child too young for immunization, illness of child and parents have no faith in immunization (12%) [Table 4]. The odds of risk of partial/non-immunization in illiterate women is 5.78 more than the graduate women (P = 0.039). The odds of risk of partial/non-immunization of the families having 4 or more children are 6.074 more than the families having 1-3 children (P < 0.0001). The odds of risk of partial/non-immunization is 45.818 in home deliveries than in institutional deliveries (P = 0.0001) [Table 5].
Discussion In present study, we have tried to find out various reasons responsible for partial or non-immunization and compared it with findings of various other studies. In the present study, 74.7% of children were fully immunized, 11.1% partially immunized and 14.1% were not immunized at all. In a study by Nath et al in Lucknow,[11] only 44.1% of children were completely immunized, which is way less than observed in our study. In a study by Joshi et al.,[12] in Bareilly district, only 50% were fully immunized and 22.5% were non-
Table 3: Immunization status of children between 12-23 months Immunization status
No. (198)
% (100)
148 22 28
74.7 11.1 14.1
Fully immunized Partially immunized Not immunized
Table 4: Reasons for partial immunization and nonimmunization of the children according to respondents Reasons Child too young for immunization Unawareness for immunization Fear of side effects Family problems Place and time of immunization not known Child was ill No faith in immunization
38
Partial immunization/ Non immunization
No. (50) (%)
6
12
10
20
8 12 2
16 24 4
6 6
12 12
immunized. In contrast to our findings, as per NFHSIII[13] only 23% children were fully immunized in Uttar Pradesh and 33.6% were not immunized at all. Kar et al.,[14] in their study in a slum of Delhi and Yadav et al.,[15] in the state of Madhya Pradesh reported a higher percentage (above 60%) of fully immunized children, which is similar to our study. In the present study, the most common reason for partial or non-immunization was family problems (24%) of the respondents followed by unawareness of immunization (20%), and fear of side effects (16%). Other reasons were child too young for immunization, illness of child, and parents having no faith in immunization (12%). In a study by Joshi et al[12], important reasons for non-immunization were lack of awareness in both the urban (28.6%) and rural (78.6%) areas and lack of availability of services in rural areas (87.2%). In a study by Nandan et al.,[16] and Chaturvedi et al[17], non-availability of services was reported to be the single most common reason for nonimmunization. According to another study by Nath et al [11] , the commonest reason for the partial immunization of the child was the unavailability of both the parents (17.2%) to fulfill the child’s health needs, as they were preoccupied in the livelihood-generation activities. This reflects the unmet needs of the community, which require organization of outreach services on fixed date and timing with prior information to the locality. Other reasons for partial immunization were missing of the dose due to visit to native place/village (14.7%) compared to 23.1% in the study done by Kar et al[14], carelessness (11.7%), apprehensiveness due to sickness of the child or an elder sibling as a result of vaccination (11.7%) and lack of knowledge (10.4% vs. 23.1% by Kar et al[14]). In the present study, illiteracy was found to be significantly associated with partial or non-immunization. Similarly Nath et al.,[11] also reported that illiteracy of the mother was significantly associated with partial immunization, and this has also been documented in other studies.[18,19] Interestingly in this study, higher illiteracy rate in male compared to female was found, which seems to be unusual according to other studies in India. Maina et al., [20] in their study found that maternal education was one of the factors that was significantly associated with immunization coverage. In Kaptembwo, the proportion of fully immunized children of mothers/ guardians who had attained secondary school education and above was 81.6%, which is higher than those who had attained primary school education (76.7%) and even those with no formal education (42.9%). Previous studies have shown a significant association between
North American Journal of Medical Sciences | Feb 2015 | Volume 7 | Issue 2 |
Gupta, et al.: Determinants of immunization in Lucknow
Table 5: Immunization status in relation to socio-demographic characteristics of the children Variable
Fully immunized
Partially/Not fully Immunized
No. (%)
No. (%)
32 (84.2) 116 (72.5)
6 (15.8) 44 (27.5)
112 (73.7) 36 (78.3)
OR
95% CI
P value
Lower
Upper
Ref. 2.023
0.791
5.171
0.141
40 (26.3) 10 (21.7)
Ref. 1.286
0.585
2.828
0.532
40 (54.1) 32 (84.2) 66 (89.2) 10 (83.3)
34 (45.9) 6 (15.8) 8 (10.8) 2 (16.7)
4.25 0.937 0.606 Ref.
0.871 0.163 0.112
20.749 5.399 3.272
0.074 0.942 0.561
18 (40.9) 50 (83.3) 72 (85.7) 8 (80.0)
26 (59.1) 10 (16.7) 12 (14.3) 2 (20.0)
5.778 0.8 0.667 Ref.
1.096 0.147 0.126
30.447 4.343 3.526
0.039 0.796 0.633
114 (81.4) 34 (58.6)
26 (18.6) 24 (41.4)
Ref. 3.095
1.577
6.074
0.001
144 (86.7) 4 (12.5)
22 (13.3) 28 (87.5)
Ref. 45.818
14.658
143.219
Determinants of Immunization Coverage in Lucknow District Pratibha Gupta, Daya Prakash, Jyoti Prakash Srivastava Department of Community Medicine, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India
Abstract Background: Immunization remains one of the most important public health interventions and a cost-effective strategy to reduce both the morbidity and mortality associated with infectious diseases. Over two million deaths are delayed through immunization each year worldwide. Aims: This study sought to identify specific factors associated with immunization coverage in order to advance improved intervention, policies/strategies therefore raising overall immunization coverage. Materials and Methods: A cross-sectional study was conducted among a total of 198 children aged 12-23 months at Urban Health and Training Centre (UHTC), Era’s Lucknow Medical College, Lucknow, over a period of 6 months i.e., from July 2012-December 2012. Data were collected, compiled and tabulated using Microsoft Excel and analyzed using SPSS 17.0 version. Results: A total of 198 children of age 12-23 months were included in this study, of which 74.7% of children were fully immunized, 11.1% were partially immunized and 14.1% were not immunized at all. The most common reason for partial or nonimmunization was family problems (24%) of the respondents followed by lack of knowledge of immunization (20%), and fear of side effects (16%). The odds of risk of partial/non-immunization in illiterate women is 5.78 more than the graduate women (P = 0.039). Conclusions: Although in the present study, majority of the children were immunized, it is still not up to the mark. We have to make it 100%, so that we can reduce mortality due to vaccine-preventable diseases. Increasing awareness and reducing fear of side effects of immunization among parents through health education, counseling, etc. can increase the percentage of immunized children.
Keywords: Children, Determinants, Immunization, Mothers, Urban areas Address for correspondence: Dr. Pratibha Gupta, 5/351, Viram Khand - 5, Gomtinagar, Lucknow-226 010, Uttar Pradesh, India. E-mail: [email protected]
Introduction Immunization remains one of the most important public health interventions and a cost-effective strategy to reduce both the morbidity and mortality associated with infectious diseases. Over two million deaths are delayed through immunization each year worldwide.[1] Despite this, vaccine-preventable diseases remain the most common cause of childhood mortality with an estimated three million deaths each year.[2] Uptake of vaccination services is dependent not only on provision of these services, but also on other factors including knowledge and attitude of mothers.[3,4] Access this article online Quick Response Code:
Website: www.najms.org
DOI: 10.4103/1947-2714.152076
36
According to the Global Routine Vaccination Coverage (GAVI) 2010, about 19.3 million children were not fully vaccinated and remained at risk for diphtheria, tetanus and pertussis, and other vaccine-preventable causes of morbidity and mortality, and about 50% of these children are from India, Nigeria, and Congo.[5] The most important indicators mentioned in the Millennium Development Goals (MDGs) are the under-5 mortality rate (U5MR), infant mortality rate (IMR) and proportion of 1-year-old children immunized against measles (P1MV). About onequarter, or 25%, of under-5 mortality is due to vaccinepreventable diseases.[6] The World Health Organization (WHO) launched the Expanded Program on Immunization (EPI) in 1974 globally with the focus on prevention of the six childhood vaccine-preventable diseases by the year 2000. This was endorsed by the Government of India in 1978.[7] Later, on November 19, 1985, the Universal Immunization Program (UIP) was introduced in India with the objective to cover at least 85% of all infants by 1990.[8]
North American Journal of Medical Sciences | Feb 2015 | Volume 7 | Issue 2 |
Gupta, et al.: Determinants of immunization in Lucknow
Further, a national socio-demographic goal was set up in National Population Policy (NPP) 2000 to achieve universal immunization of children against all vaccinepreventable diseases by 2010.[9] In addition, evaluation of immunization coverage provides evidence whether substantial progress toward achieving vaccination targets is being made. Such positive evidence is required for continuing support from donor supported initiatives like the Global Alliance for Vaccines and Immunizations (GAVI).[10] The current study seeks to determine whether the situation has improved since and to more fully identify risk groups and reasons for under-immunization. This study sought to identify specific factors associated with immunization coverage in order to advance improved intervention, policies/strategies and therefore raising overall immunization coverage.
Materials and Methods The present study is a cross-sectional study conducted among children aged 12-23 months at Urban Health and Training Centre (UHTC), Era’s Lucknow Medical College, Lucknow, for a period of six months i.e., from July 2012 to December 2012.
for calculation of percentages, and Chi-square test was applied to find out various statistical associations.
Results A total of 198 children of 12-23 months of age were included in this study of which 100 were males and 98 were females. Total 80.8% of children were Muslims and 19.2% were Hindus. In all, 76.8% of children belonged to nuclear families and 23.2% belonged to joint families. Parents of most of the children were educated. Only 37.4% of fathers and 22.2% of mothers were illiterate [Table 1]. Among immunized children, majority (83.8%) of the children were delivered at government/private hospital and only 16.2% of the children were delivered at home [Table 2]. Immunization status was ascertained by mother’s recall accompanying the child. In present study 74.7% of children were fully immunized, 11.1% partially immunized and 14.1% were not immunized at all. The
Table 1: Socio-demographic characteristics of children between 12-23 months Variables
Sampling technique The present study was conducted during July 2012 -December 2012. A total of 198 children aged 12-23 months attending outpatient department (OPD) at Urban Health and Training Centre (UHTC), Era’s Lucknow Medical College, Lucknow were included in the study. This study was conducted after the ethical clearance from the ethical committee of Era’s Lucknow Medical College, Lucknow.
Tools of data collection The investigating tool used is a preformed, pretested questionnaire. Questions regarding biosocial characteristics and immunization status of the children were asked from the mother accompanying the child. In case the mother was not present, then any other person accompanying the child was interviewed regarding biosocial characteristics and immunization status. As this study was conducted among mothers attending OPD at urban health center, so the immunization status was determined on the basis of mother’s recall and record at the urban health center. Definitions of key indicators were taken from NFHS-3, India.
No. (198)
% (100)
38 160
19.2 80.8
152 46
76.8 23.2
100 98
50.5 49.5
74 38 74 12
37.4 19.2 37.4 6.1
44 60 84 10
22.2 30.3 42.4 5.1
140 58
70.7 29.3
Religion Hindu Muslim Type of family Nuclear Joint Gender Male Female Father’s education Illiterate Primary/Junior Secondary Graduate and above Mother’s education Illiterate Primary/Junior Secondary Graduate and above No. of living children within the family 1-3 4 and above
Table 2: Place of birth
Statistical analysis
Place
Data were collected, compiled and tabulated using Microsoft Excel and analyzed using SPSS 17.0 version
Govt./Private hospital Home
North American Journal of Medical Sciences | Feb 2015 | Volume 7 | Issue 2 |
No. (198)
(%)
166 32
83.8 16.2
37
Gupta, et al.: Determinants of immunization in Lucknow
percentage of non-immunized children were more among female children (20%) [Table 3]. Most common reason for partial or non-immunization was family problems (24%) of the respondents followed by unawareness of immunization (20%), and fear of side effects (16%). Other reasons were child too young for immunization, illness of child and parents have no faith in immunization (12%) [Table 4]. The odds of risk of partial/non-immunization in illiterate women is 5.78 more than the graduate women (P = 0.039). The odds of risk of partial/non-immunization of the families having 4 or more children are 6.074 more than the families having 1-3 children (P < 0.0001). The odds of risk of partial/non-immunization is 45.818 in home deliveries than in institutional deliveries (P = 0.0001) [Table 5].
Discussion In present study, we have tried to find out various reasons responsible for partial or non-immunization and compared it with findings of various other studies. In the present study, 74.7% of children were fully immunized, 11.1% partially immunized and 14.1% were not immunized at all. In a study by Nath et al in Lucknow,[11] only 44.1% of children were completely immunized, which is way less than observed in our study. In a study by Joshi et al.,[12] in Bareilly district, only 50% were fully immunized and 22.5% were non-
Table 3: Immunization status of children between 12-23 months Immunization status
No. (198)
% (100)
148 22 28
74.7 11.1 14.1
Fully immunized Partially immunized Not immunized
Table 4: Reasons for partial immunization and nonimmunization of the children according to respondents Reasons Child too young for immunization Unawareness for immunization Fear of side effects Family problems Place and time of immunization not known Child was ill No faith in immunization
38
Partial immunization/ Non immunization
No. (50) (%)
6
12
10
20
8 12 2
16 24 4
6 6
12 12
immunized. In contrast to our findings, as per NFHSIII[13] only 23% children were fully immunized in Uttar Pradesh and 33.6% were not immunized at all. Kar et al.,[14] in their study in a slum of Delhi and Yadav et al.,[15] in the state of Madhya Pradesh reported a higher percentage (above 60%) of fully immunized children, which is similar to our study. In the present study, the most common reason for partial or non-immunization was family problems (24%) of the respondents followed by unawareness of immunization (20%), and fear of side effects (16%). Other reasons were child too young for immunization, illness of child, and parents having no faith in immunization (12%). In a study by Joshi et al[12], important reasons for non-immunization were lack of awareness in both the urban (28.6%) and rural (78.6%) areas and lack of availability of services in rural areas (87.2%). In a study by Nandan et al.,[16] and Chaturvedi et al[17], non-availability of services was reported to be the single most common reason for nonimmunization. According to another study by Nath et al [11] , the commonest reason for the partial immunization of the child was the unavailability of both the parents (17.2%) to fulfill the child’s health needs, as they were preoccupied in the livelihood-generation activities. This reflects the unmet needs of the community, which require organization of outreach services on fixed date and timing with prior information to the locality. Other reasons for partial immunization were missing of the dose due to visit to native place/village (14.7%) compared to 23.1% in the study done by Kar et al[14], carelessness (11.7%), apprehensiveness due to sickness of the child or an elder sibling as a result of vaccination (11.7%) and lack of knowledge (10.4% vs. 23.1% by Kar et al[14]). In the present study, illiteracy was found to be significantly associated with partial or non-immunization. Similarly Nath et al.,[11] also reported that illiteracy of the mother was significantly associated with partial immunization, and this has also been documented in other studies.[18,19] Interestingly in this study, higher illiteracy rate in male compared to female was found, which seems to be unusual according to other studies in India. Maina et al., [20] in their study found that maternal education was one of the factors that was significantly associated with immunization coverage. In Kaptembwo, the proportion of fully immunized children of mothers/ guardians who had attained secondary school education and above was 81.6%, which is higher than those who had attained primary school education (76.7%) and even those with no formal education (42.9%). Previous studies have shown a significant association between
North American Journal of Medical Sciences | Feb 2015 | Volume 7 | Issue 2 |
Gupta, et al.: Determinants of immunization in Lucknow
Table 5: Immunization status in relation to socio-demographic characteristics of the children Variable
Fully immunized
Partially/Not fully Immunized
No. (%)
No. (%)
32 (84.2) 116 (72.5)
6 (15.8) 44 (27.5)
112 (73.7) 36 (78.3)
OR
95% CI
P value
Lower
Upper
Ref. 2.023
0.791
5.171
0.141
40 (26.3) 10 (21.7)
Ref. 1.286
0.585
2.828
0.532
40 (54.1) 32 (84.2) 66 (89.2) 10 (83.3)
34 (45.9) 6 (15.8) 8 (10.8) 2 (16.7)
4.25 0.937 0.606 Ref.
0.871 0.163 0.112
20.749 5.399 3.272
0.074 0.942 0.561
18 (40.9) 50 (83.3) 72 (85.7) 8 (80.0)
26 (59.1) 10 (16.7) 12 (14.3) 2 (20.0)
5.778 0.8 0.667 Ref.
1.096 0.147 0.126
30.447 4.343 3.526
0.039 0.796 0.633
114 (81.4) 34 (58.6)
26 (18.6) 24 (41.4)
Ref. 3.095
1.577
6.074
0.001
144 (86.7) 4 (12.5)
22 (13.3) 28 (87.5)
Ref. 45.818
14.658
143.219
